Erika Springer’s patients can be unpredictable and aggressive. She takes comfort in knowing someone has her back.
The nurse says that wasn’t always the case at her old job at Western State Hospital, which she left in May after less than two years.
“There is a much greater sense of safety when things begin to escalate,” Springer said of her new workplace, University of Washington-run Harborview Medical Center. “We have a lot more people that are prepared to intervene. We don’t have to wait for people to come from other units to provide assistance for patients whose agitation levels are escalating.”
State officials say an extreme shortage of staff at Western State Hospital is a major reason federal regulators declared patients’ safety to be in danger before lifting that finding Tuesday.
Trouble hiring and keeping staff is also cited as a reason the 827-bed hospital has failed to obey court orders to examine criminal defendants within a week, and a factor in why its wait list has grown to 60 noncriminal patients, causing cascading effects through Washington’s mental-health system, which includes more detentions in local hospitals.
Western State Hospital doesn’t have enough social workers, psychologists, nurses and — most critically — registered nurses and psychiatrists, Department of Social and Health Services Secretary Kevin Quigley told state lawmakers in an e-mail Monday.
In September, six months into what officials said is an aggressive recruitment drive that has brought on hundreds of new employees, about 15 percent of all jobs at the hospital remained empty, leaving more than 300 vacancies.
It ends up costing more money in the end pinching pennies that it does to pay extra staff to be present on each shift
Erika Springer, former Western State Hospital nurse
Vacancies for registered nurses mirrored the total share with more than 50 empty positions. For psychiatrists, it was more severe. Ten of 45 were vacant, which grew to 12 by Nov. 12 — leaving more than one in four positions empty.
While direct comparisons with previous years were not immediately available, hospital CEO Ron Adler told lawmakers in November 2013 that the division comprising most of the hospital had a vacancy rate at the time of 4 percent or less.
Short-staffing, though, appears to be chronic.
Just two months earlier in 2013, a report commissioned by a nurses’ union and DSHS deemed staffing at Western State Hospital in Lakewood and Eastern State Hospital near Spokane too “lean” to fulfill the facilities’ mission.
In 2012, researchers with the state Department of Labor and Industries surveyed employees at Western State Hospital and found they mentioned staffing shortages more than any other need.
Workers who talked to L&I linked unsafe levels of staffing to assaults, poor morale, high turnover, difficulty scheduling time off, frequent unscheduled absences and reliance on overtime to the point of employee burnout.
Employees and administrators mentioned all of those as problems in 2015.
“As soon as staff can get a private-sector job, they leave the state psychiatric hospital. So that constant turnover leaves them short-staffed,” said Nanette Yraguiso, an L&I occupational-health research psychologist who co-wrote the 2012 report. “It’s really, really hard, and then you have new and inexperienced staff that need all that training on how to work with psychiatric patients.”
Reported assaults on staff at Western State Hospital have been on the decline, with many fewer in recent years than in the previous decade. Even so, employees in roughly the first half of this year reported an average of one assault per day.
That’s according to figures provided to L&I, which reflect assault rates that are on track to increase from the previous year. L&I data also show employees using emergency alarms to call for help an average of four times a day.
One nurse at the hospital, Michele Liedtke, complained the hospital moved a patient to her ward this week who had a history of harassing her.
She said a flurry of assaults have occurred recently on her high-security ward and blamed it on staff being moved onto and off of the ward, with some incoming workers unfamiliar with the ward’s patients. Patients need stability, she said.
As part of its improvement plan, the hospital said it wouldn’t remove workers from wards like hers that tend to have more dangerous patients, and it would reduce instances of employees being placed on unfamiliar wards.
Liedtke said her job comes with good benefits but plenty of stress and not enough respect from top management.
“The pay is not the huge issue there,” she said. “The huge issue there is they don’t consider our safety.”
14.8 percentVacancy rate at Western State Hospital as of Sept. 25. Out of 2,109 full-time equivalent positions, 312 were vacant.
CHANGES ON THE WAY
It’s easy for a psychiatric hospital’s staffing plan to fall apart because of emergencies, said Jonathan Rosen, a consultant to unions and others on workplace violence prevention. He performed the 2013 study.
“If you have a patient who’s agitated or violent, all of a sudden you need to have a one-to-one staffing on that patient,” Rosen said. “All of a sudden one of your few staff is spending 100 percent of their time on one patient.”
Until recently, Western State Hospital didn’t send reinforcements to wards just because an employee was occupied providing one-on-one attention. Until a second patient needed monitoring as well, the ward was expected to “absorb” the extra burden.
But as part of passing the latest inspection and lifting a threat of losing federal funding, the hospital told regulators it would start sending an extra employee as backup in those situations — if the patient being monitored poses a danger to others. No backup was promised for cases of a patient being monitored for endangering himself.
Quigley wrote that at least 60 extra employees are needed to implement the change. Overtime would presumably increase to cover those shifts if the hospital can’t raise its staff numbers.
DSHS, which has said it’s already struggling with overtime, promised regulators it would take time to train employees in de-escalating tense situations. Quigley wrote that he has authorized increased overtime to allow for more training.
Overtime is typically voluntary but sometimes mandated to cope with low staffing. Adler told employees in a newsletter Wednesday there may be need for mandatory overtime during the holidays.
The squeeze is putting additional pressure on employees, said Liedtke, the Western State nurse. She said the hospital has rejected vacation requests because of a lack of staff.
“When people are told over and over that they can’t have a day off, that they have to go and work someplace that they’ve never worked before, it creates that stressful situation where, if you’re not going to be given the time to regenerate yourself, you’re going to take it at some point, or you’re going to get sick,” she said. “Mental health is not for the faint of heart.”
DSHS also plans to address staffing by contracting for outside psychiatrists, and by holding onto employees who were hired to staff an expansion that was canceled to improve safety.
827 Beds for patients at Western State Hospital. Officials say the hospital has been running near full capacity.
PAY GOING UP
Quigley’s announced changes also include a series of increases to pay and benefits, including recruitment incentives for psychiatrists and registered nurses.
DSHS officials say they are struggling to compete for mental-health providers against the private sector and against federal agencies with a presence in Pierce County. Adler said a social worker recently left his $54,000-a-year job at the hospital to earn $94,000 as admissions director for a private employer.
The hospital’s biggest staffing challenge is a lack of psychiatrists, said Victoria Roberts, a DSHS deputy assistant secretary.
Recognizing the problem, the state and unions negotiated an extra raise and a bonus for psychiatrists and DSHS dipped into its budget to maintain a 15 percent raise that the Legislature had briefly funded.
That brings average pay for the type of psychiatrist employed at Western State Hospital to $206,002, according to DSHS.
The Veterans Affairs Puget Sound Health Care System, often cited as a competitor, said it pays psychiatrists an average of $201,418.
State pay is still short of what psychiatrists earn at Madigan Army Medical Center, an average of $234,701.
Dr. Glenn Morrison, a Western State psychiatrist, said there are positions in the area that pay tens of thousands more than what Western can offer new hires.
“They are just not paying enough to attract people,” Morrison said.
Pay doesn’t provide immunity to recruitment problems. Madigan actually has a higher rate of psychiatrist vacancies than Western State despite higher pay and a generally less volatile environment. Five of its 12 psychiatrist positions are empty.
Madigan tends to keep psychiatrists once it hires them, but has trouble recruiting, said Ryan Lindgren, chief administrative officer for behavioral health.
“We’re not getting lots of applications,” Lindgren said. “It’s hard because we know we pay well, but finding those psychiatrists is difficult.”
Psychiatrists are lacking nationwide, Roberts said: “There literally are just not enough to go around.”
A few months into his job as CEO in 2013, Adler urged lawmakers “to think differently about staffing and staffing ratios,” saying more employees isn’t necessarily better and in fact, “when you add more people to a (ward) where there’s a potential for violence, more people get hurt.”
Today, Adler says more staff should be added but in a targeted way, which he said is also what has a history of winning funding from lawmakers.
The latest state budget added money for more staff but largely targeted it to areas of need identified by DSHS, such as emergency-response teams, or to new wards that now aren’t opening soon.
Lawmakers funded about half of a request for more staff to cover vacancies during safety training addressing problems found by state regulators from L&I.
Some employees are critical of management for not adding staff for basic patient care until forced by the threat of lost funding.
“Those of us that work everyday with patients feel a sense of futility as we’re asked to put more efforts into paperwork fixes which simply give the illusion of care,” Dr. Joseph Wainer wrote in a letter published in The News Tribune this month. “Yet, our desperate requests for more time and more people to work with patients have been marginalized as naive and simply ignored.”
Wainer had authored an August memorandum outlining recommendations from a committee of doctors for more staff. The letter cited a 2008 report commissioned by DSHS in which an expert on psychiatric treatment recommended assigning psychiatrists to no more than 24 patients each and other doctors to no more than 48 patients.
Wainer wrote that on many days, physicians have been responsible for 90 to 120 patients.
Morrison said doctors were told in response to the memo that what they saw as safety problems were matters to be handled through union negotiations. Adler said labor regulations restrict him from being able to discuss with employees issues that have been formally raised by unions.
Adler said at Western, there’s an unfortunate tendency to see staffing needs “like an automobile manufacturer,” with need for a set number of staff regardless of the kind of patients.
In reality, Adler said, employee numbers are less important than the way staff are used.
The more acute the condition of a patient, the more staff are needed. Patients being admitted to the hospital tend to have the most acute conditions, he said.
“We would actually be running a safer hospital if we could staff up the admissions wards and maybe staff down some of the lower-acuity wards,” Adler said, “but the culture at Western just wouldn’t look at that yet.”